Provider Demographics
NPI:1609915495
Name:GRAVELINE, PATRICK JOSEPH (PSYD, BCBA-D)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:JOSEPH
Last Name:GRAVELINE
Suffix:
Gender:M
Credentials:PSYD, BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1542 ANDOVER LN
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-3722
Mailing Address - Country:US
Mailing Address - Phone:402-613-5950
Mailing Address - Fax:
Practice Address - Street 1:10435 DOWNSVILLE PIKE
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-1732
Practice Address - Country:US
Practice Address - Phone:301-766-8222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 103K00000X
MD4582103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD252502000Medicaid